DEFINATION Fever Alteration of sensorium Focal neurological anomalies

By dr. abhishek singh

etiology
Infectious

Virus-most common Bacteria Protozoa Fungus Helminthes Noninfectiouslupus,vascultis,paraneoplastic syndromes

D/D OF ENCEPHALITIS
ADEM

Post infectious/vaccination ENCHEPHALOPATHY(secondary) Brain abscess

Approach to management
Investigation for etiological agent(?)
Diagnostic tests Empirical management

Specific management
Supportive care

Diagnosis
Should be individualized
Epidemiologic clues and assessment of risk factors . Clinical clues (general and specific neurologic

findings) History of recent infectious illness or vaccination, possible diagnosis of ADEM .

Epidemiological clues
Age
Geography Season of the year

Prevalence of disease in the local community

Travel history, Recreational activities Occupational exposure, insect contact, animal contact Vaccination history and immune status of the patient.

Clinical presentation
General findings Lymphadenopathy HIV, EBV, CMV, measles ,

rubella , M.tuberculosis, Toxoplasma Parotitis Mumps virus Rash VZV, rubella, enteroviruses, HIV, Rickettsia , Mycoplasma ,Borrelia burgdorferi Respiratory tract - influenza virus, adenovirus, M. pneumoniae, M. tuberculosis, H.capsulatum

Clinical presentation
Neurologic findings

Cerebellar ataxia VZV (children), EBV, mumps virus, Cranial nerve abnormalities Herpes simplex virus, Epstein-Barr virus, Listeria monocytogenes, M. tuberculosis Retinitis--CMV

Clinical presentation
Dementia HIV, SSPE
Parkinsonism

Japanese encephalitis virus Poliomyelitis-like flaccid paralysis Japanese encephalitis virus, West Nile virus, tickborne encephalitis virus; enteroviruses(enterovirus-71, coxsackieviruses), poliovirus

Neuroimaging studies
Neuroimaging studies

MRI -most informative CT PET Electroencephalography (EEG)

MRI
Neuroimaging investigation of choice
Detect early changes(encephalitis vs. ADEM) Gives clue in some cases regarding etiological

agent(HSV) Disadvantage Costly, time consuming May be normal in HSV Enc in early stage

CT SCAN
Not investigation of choice
Does not pick up early encephalitic stage Helps to rule out tumor, brain abscess

EEG
rarely useful in diagnostic purpose (HSV)
Detects electrical discharge in comatose patient Does not indicate the severity of illness

HSVclassical PLEDS discharge

JEV- diffuse delta pattern

EEG pattern in HSV(PLEDS)

Blood/CSF
CBC
Blood culture LFT

KFT
Coagulation studies Chest x ray CSF

CSF- findings
Pressure
Cell count Biochemistry

Culture

Diagnostic Studies in the CNS

presence of virus-specific IgM in CSF arbo virus,VZV
Nucleic acid amplification tests (such as PCR)

interpretation Herpes simplex PCR -recommended Viral cultures of CSF not recommended Brain biopsy not routinely recommended

PCR
High sensitivity and specificity in adults
Newborn, infants sensitivity is 75% Can be negative

Rpt PCR should be done if first sample is negative

Brain biopsy
Not routinely recommended
Diagnosis in confusion Clinical detoriation

On acyclovir no improvement
Should be done early rather late

Diagnostic Studies outside the CNS

Cultures of body fluid

specimen(nasopharynx,sputum,stool,respiratory secretions) detection of IgM antibodies(ELISA) in serumArbovirus,VZV,lyme disease acute and convalescent-phase serum samples are not usefulfor retrospective diagnosis Nucleic acid amplification tests (such as PCR)

Treatment(IDSA guidelines)
Empirical Therapy

IV Acyclovir Dose Duration Empirical antimicrobial agents Suspected rickettsial or ehrlichial infection doxycycline should be added .

Specific therapy
Antiviral
Acyclovir-HSV,VZV Gancyclovir-CMV

Oseltamivir-INFLUENZA
Rivabarin- measeles HAART-HIV

Adjunctive therapy
Corticosteroids-good evidence, beneficial in both bac. meningitis and encephalitis
Management of raised ICP

Nutrition
Prevention of secondary infection Seizure control

Bladder , bowel care

complications
Mortality Morbidity

Long term sequel

Prognostic factors(HSV)
Age >30 yr
GCS <6 initiation of acyclovir after 4 days

Long term sequel

Epilepsy
Personality changes Memory disturbance

Hearing loss/visual disturbances

Follow up for at least 1 yr

prevention
Vaccination
MMR vaccine VZV vaccine

JEV vaccine
Anti rabies vaccine Polio vaccine

SUMMARY OF RECOMMENDATIONS
Etiological investigations should be done.
Neuro imaging should be done before L.P. MRI is the investigation of choice.

CSF PCR is recommended.

I.V. acyclovir as empirical treatment strongly

recommended.

continued.

 Antibiotics should be started as empirical treatment

for ABM. Anti-malarial is recommended as empirical therapy in endemic area for cerebral malaria. Steroids is recommended. No specific treatment available(except HSV) Should be on follow-up for 1 year.

Thank u

 Cats Dogs Horse

vir Rodents Eastern equine encephalitis virus (South America), tickborne encephalitis virus Sheep and goats C. burnetii Swine Japanese encephalitis virus, Nipah virus White- tailed deera Borrelia burgdorferi Immunocompromised persons Varicella zoster virus, cytomegalovirus, human herpesvirus 6, HIV, L. monocytogenes, Mycobacterium tuberculosis, C. neoformans, Coccidioides species, Histoplasma capsulatum, T. gondii

Rabies virus, Coxiella burnetii, Bartonella henselae, T. gondii Rabies virus Eastern equine encephalitis virus, Western equine encephalitis

 Ingestion items
Raw or partially cooked meat T. gondii Unpasteurized milk Tickborne encephalitis virus, L. monocytogenes, C. burnetii

Insect contact
Mosquitoes Eastern equine encephalitis virus, Western equine encephalitis virus, St. Louis encephalitis virus, Japanese encephalitis virus, West Nile virus, Plasmodium falciparum Sandflies Bartonella bacilliformis Ticks Tickborne encephalitis virus, Rickettsia rickettsii, Ehrlichi, B.burgdorferi Tsetse flies Trypanosoma brucei gambiense, Trypanosoma brucei rhodesiense

Occupation
Exposure to animals Rabies virus, C. burnetii, Bartonella spec

 Physicians and health care workers Varicella zoster virus, HIV, influenza , measles , M.tuberculosis Person-to-person transmission Herpes simplex virus (neonatal), varicella zoster virus, poliovirus, nonpolio enteroviruses,measles virus, mumps virus, rubella virus, Epstein-Barrvirus,

human herpesvirus 6, HIV, rabies virus (transplantation),influenza virus, M. pneumoniae, M. tuberculosis, T. pallidum Recent vaccination Acute disseminated encephalomyelitis Recreational activities Camping/hunting All agents transmitted by mosquitoes and ticks (see above) Sexual contact HIV, T. pallidum Swimming Enteroviruses, Naegleria fowleri

 Season

Late summer/early fall All agents transmitted by mosquitoes and ticks (see above),enteroviruses Winter Influenza virus Transfusion and transplantation Cytomegalovirus, Epstein-Barr virus, West Nile virus, HIV, tickborneencephalitis virus, rabies virus, iatrogenic CJD, T. pallidum, A. phagocytophilum,R. rickettsii, C. neoformans, Coccidioides species, H.capsulatum, T. gondii

 India, Nepal

Rabies virus, Japanese encephalitis virus, P. falciparum Middle East West Nile virus, P. falciparum Southeast Asia, China, Pacific Rim Japanese encephalitis virus, tickborne encephalitis virus, Nipah virus,P. falciparum, Gnanthostoma species, T. solium Unvaccinated status Varicella zoster virus, Japanese encephalitis virus, poliovirus, measlesvirus, mumps virus, rubella virus

Table 1. Infectious Diseases Society of AmericaUS Public Health Service Grading System for ranking recommendations in clinical guidelines.

Strength of recommendation A Good evidence to support a recommendation for use B Moderate evidence to support a recommendation for use C Poor evidence to support a recommendation Quality of evidence I Evidence from 1 properly randomized, controlled trial II Evidence from 1 well-designed clinical trial, without randomization; from cohort or case-controlled analytical studies (preferably from 11 center); from multiple time-series; or from dramatic results from uncontrolled experiments III Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

 Antibacterial:
Bartonella henselae: Listeria monocytogenes:

Mycoplasma pneumoniae:
Mycobacterium tuberculosis: Mycobacterium tuberculosis: Spirochetes

Protozoa
Acanthamoeba:
Naegleria fowleri: Plasmodium falciparum:

Toxoplasma gondii:

Table 2. Possible etiologic agents of encephalitis based on epidemiology and risk factors.
Epidemiology or risk factor Possible infectious agent(s)
Ag Age Neonates Herpes simplex virus type 2, cytomegalovirus, rubella virus, Listeria monocytogenes, Treponema pallidum, Toxoplasma gondii

Infants and children Eastern equine encephalitis virus, Japanese encephalitis virus, influenza virus,
Animal contact Bats Rabies virus, Nipah virus Birdsa West Nile virus, Eastern equine encephalitis virus, Western equine encephalitis virus, St. Louis encephalitis virus, Japanese encephaliti, Cryptococcus neoformans (bird droppings)

Cats Rabies virus, Coxiella burnetii, Bartonella henselae, T. gondii Dogs Rabies virus Horsesa Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, Hendra virusb Old World primates B virus Raccoons Rabies virus, Baylisascaris procyonis Rodentsa Eastern equine encephalitis virus (South America), Venezuelan equine encephalitis virus, tickborne encephalitis virus, Powassan virus (woodchucks), La Crosse virus (chipmunks and squirrels), Bartonella quintanab Sheep and goats C. burnetii Skunks Rabies virus Swinea Japanese encephalitis virus, Nipah virusb White-tailed deera Borrelia burgdorferi Immunocompromised persons Varicella zoster virus, cytomegalovirus, human herpesvirus 6, West Nile virus, HIV, JC virus, L. monocytogenes, Mycobacterium tuberculosis, C. neoformans, Coccidioides species, Histoplasma capsulatum, T. gondii

ENTEROVIRUS
Rash +aseptic meningitis
Late summer/fall Swimming

Unusual cause of encephalitis

50% csf no pleocytosis Pcr communicable

MEASLES
Rash +encephalitis
1 in 1000 cases usually self limiting , can be fulminant Mainly causes encehalomylitis(ADEM)

Csf- anti measeles antibody

SSPE-more with natural infection rather than

vaccination ,nat infect within 2 yr sspe